Healthcare Provider Details

I. General information

NPI: 1780799361
Provider Name (Legal Business Name): SCOTT CHRISTOPHER SUNTRUP DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E 2ND ST
FLORA IL
62839-2034
US

IV. Provider business mailing address

217 E 2ND ST
FLORA IL
62839-2034
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-5116
  • Fax: 618-403-5996
Mailing address:
  • Phone: 618-662-5116
  • Fax: 618-403-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019027276
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: